Throat cut
Abstract: The present prospective autopsy study was carried out during the period July 2009 to May 2012 in Kingston, Jamaica. A total of 74 cases of cut throat injury were studied. All the cut throat injuries irrespective of those directly or indirectly contributing to the death were studied. Males dominated the list of victims, contributing to 71.62% (n = 53). Majority of those were in the age group 21–30 (n = 25) and 31–40 (n = 26) which contributed to 33.78% and 35.13% respectively. Majority of the cases were homicides contributing to 97.29% (n = 72) of cases, only 2.7% were suicides and accidental cut throat were never reported. Males dominated the homicides category contributing to 72.22% (n = 52) of the cases. Gang and relationship crisis (homosexual and heterosexual) were the major motivating factors, each contributing to 39.19% (n = 29) and 32.43% (n = 24) of the cases, respectively. The disease suffered by individuals were the least motivating factors contributing to 1.35% of cases (n = 01). The most common cause of death was exsanguinations in 49.95% (n = 34) of cases followed closely by asphyxia due to aspiration of blood i.e. 36.49% (n = 27) of cases and air embolism was the least cause of death, contributing to 4.05% (n = 03) of cases. Cut throat injury was associated with other injuries like gunshot wound, chop wounds and stab wounds in 13.52% of (n = 10) autopsies. Chop injuries contributed to maximum number of other injuries in homicides (n = 46). The most preferred place for the crime was an open field or farm (n = 26). Majority of the cut throat wounds were situated in zone II level contributing to 66.21% (n = 49) of cases. Majority of the wounds were directed from left to right in 75.68% (n = 56) of cases and the cervical vertebra was affected in 8.11% (n = 06) of cases. Major weapon of choice was machete contributing to 83.78% (n = 62) of injuries. The low income group was Cut throat injury Machete Weapon Neck Cervical vertebra 1. Introduction In vertebral anatomy, the throat (Latin: Gula ) is the anterior part of the neck, in front of the vertebral column . It consists of larynx , trachea, pharynx, vital blood vessels – carotid and jugular, oesophagus, cricoid, thyroid and hyoid bone. It is sometimes considered a synonym for fauces.1 Anterior neck injuries are varied in extent, case and extent, and they may be intentional or accidental.2,3 The present prospective study was carried out between July 2009 and May 2012 in Kingston. All the cut throat injuries examined, irrespective of the injury directly or indirectly contributing to the death were studied. Injuries to the throat comprises one of the major methods adopted to kill or as a mean to severe the head, so as to conceal the victims identity or as a mode of revenge. With the presence of vital blood vessels, nerves and wind pipe, the neck constitutes one of the most vital structures of the body as any damage to this structure invites fatality as death is imminent.4–6 There are many instances wherein cut throat injuries do exist with other type of injuries. Hence it is essential to find out the fatal injury and the reason behind those injuries, besides other factors associated with the pattern like the direction of injury, underlying damages, the level of neck affected, and the causes of death. All these are essential to give an insight into understanding the medico legal aspects of wounds in specific and the clinical management in general. Hence, the present autopsy study is an attempt to study cut throat injury in all its aspects. 2. Materials and methods In the present prospective autopsy study a total of 74 cases were studied during the period between July 2009 and May 2012. All these cases are those referred to the Legal Medicine Unit, Kingston, Jamaica. Autopsy was carried out on the coroner’s request sent through the police. A complete autopsy was conducted in all the cases with enbloc removal of organs sparing the neck. The neck was last to be dissected to facilitate the so called the blood less field dissection. The injury over the neck was dissected layer by layer. The vessels, nerves, larynx, trachea, cricoid, thyroid, hyoid, pharynx, and ribbon muscles of the neck were carefully dissected to study the wounds. All the demographic details, history provided by the police/coroner and injury details were entered in a standard proforma and analysed. 3. Results Fig. 1 indicates the age and sex distribution. In the present study a total of 74 autopsy cases were studied. The males dominated with 71.62% (n = 53) of cases and the females with 28.38% (n = 21) of cases, the male to female ratio being 3.5:1. The common age group affected was the 3rd and 4th decades, with 33.78% and 35.14%, respectively. Figure 1. Age and sex distribution. Table 1 indicates the manner of death. 97.29% of the cut throat injuries were homicidal in nature, only 2.7% were suicidal in nature. No accidental injuries to the neck were reported. Table 1. Manner of death. Manner of death Suicide Accident Homicide Undetermined Male 02 00 52–72.22% 00 Female 00 00 20–27.78% 00 Percentage 2.7% 00 97.29% 00 Fig. 2 indicates the motivating factors contributing to cut throat injuries. Majority of the cut throat injuries were as a result of gang related violence, contributed to 39.19% (n = 29), followed closely due to relationship related (homosexual and heterosexual) contributing to 32.43% (n = 24). The least contributing factor is cut throat injury as a result of an inherent disease factor. Figure 2. Motivating factors. Fig. 3 indicates different causes of death. Major cause of death was exsanguinations’ contributing to 49.95% (n = 34) of deaths followed by deaths as a result of asphyxia due to inhalation of blood, 36.49% (n = 27), and the least noted cause of death was due to air embolism specific to the jugular vein. In 13.51% of cases (n = 10) cut throat injury was secondary to other fatal injuries like gunshot wound, chops and stab wounds. Figure 3. Causes of death. Fig. 4 indicates the places of occurrence. Majority of the incidents of cut throat injuries were reported from a field or farm contributing to 35.14% (n = 26), followed closely by cases reported from place of residence, home, 24.32% (n = 18). The least reported were from inside locked room – 2.70% (n = 2). In 5.41% of (n = 04) cases reported the body was found away from the unknown crime scene. Figure 4. Place of occurrence. Table 2 indicates different types of injuries, associated with the cut throat injury. Chop wounds were the major type of injuries present on the other parts of the body (n = 46). Stab (n = 18), laceration (n = 12) and gunshot (n = 07) wounds were also found to be associated with cut throat injury in the descending order. Table 2. Associated with other injuries. Nature of injuries Suicide Homicide Accident Abrasion Nil Nil Nil Contusion Nil Nil Nil Laceration Nil 12 Nil Stab 01 18 Nil Chop 00 46 Nil Gunshot wound Nil 07 Nil Burns Nil 02 Nil Table 3 indicates the socioeconomic group of the victims. The low socioeconomic class was the most affected contributing to 91.89% (n = 68) of cases, followed by high economic class contributing to 5.41% (n = 04). The middle income group was left untouched. Table 3. Socioeconomic group of victims. Manner of death Low income group Average income group High income group Suicide 00 00 02 Homicide 68 00 02 Accident 00 00 00 Table 4 indicates the wound description with particular reference to its margins, direction, zonal level of the neck involved and type of weapon. 75.68% (n = 56) of the cut throat injury were directed from left to right and only 24.32% (n = 18) were directed from right to left. Major portion of the injury involved zone II contributing to 66.21% (n = 49) of cases. Zone I was involved in 32.43% (n = 24) of cases and zone III was affected in 1.35% (n = 01) of cases. The commonest weapon of choice was machete, in 83.78% (n = 62) of cases, followed by meat cleaver, in 10.81% (n = 08) of cases. Axe was the least choice of weapon and was used only in 2.7% (n = 02) of cases. Table 4. Wounds margin, direction, zonal distribution and weapon type. Wound Total No. Percentage (%) Clean cut margin 62 83.78 Contused margin 12 16.22 Right to left direction 18 24.32 Left to right direction 56 75.68 Zone–I 24 32.43 Zone–II 49 66.22 Zone–III 01 1.35 Machete 62 83.78 Kitchen knife 02 2.7 Meat cleaver 08 10.81 Axe 02 2.7 Table 5 indicates the neck structures involved. Table 5. Neck structures affected. Neck structures Total No. Percentage (%) Platysma, sternocleidomastoid 42 56.76 Carotid artery 68 91.89 Jugular veins 74 100 Thyroid cartilage 08 10.81 Larynx and trachea 68 91.89 Oesophagus 14 18.92 Cervical vertebrae 06 8.12 The skin, platysma and external jugular veins were involved in all the cases of cut throat injury. The cervical vertebrae were least affected and involved in 8.12% (n = 06) of cases. The larynx, trachea, carotid and internal jugular vessels were involved in 91.89% (n = 68) of cases. The sternocleidomastoid was involved in 56.76% (n = 42) of cases. The oesophagus and thyroid cartilage were involved in 18.92% (n = 14) and 10.81% (n = 08) of cases. 4. Discussion In the present study 74 autopsy cases with cut throat injuries were studied irrespective of those directly or indirectly contributing to death. The males were the major sex group affected, contributing to 71.62% of cases, with a male to female ratio of 3.5:1, similar with the observations made by Buchade et al.7 and Ozdemir et al.8 The individuals belonging to the 3rd (33.78%) and 4th decades (35.14%) of life were most affected in the present study, similar with the observations made by Iseh and Obembe.10 Aich et al.9 in their study observed that 61.19% of the victims belonged to the 3rd decade, which is contrary to the observations made in the present study. In the present study, the majority of the cut throat injuries were homicidal in nature, contributing to 97.29% of cases and the least were due to self infliction, in 2.7% of cases. These observations are close to those made by Aich et al.,9 wherein they recorded 71.64% of homicide cases. However, contrary observations were expressed by Onotai and Ibekwe,11 Gilyoma et al.12 and Iseh and Obembe.10 In the present study the commonest motivating factors in homicides were gang related violence, contributing to 39.19% of cases, followed by relationship crisis (homosexual and heterosexual) contributing to 32.43%. These results are close to those observations made by Buchade et al.7 wherein they reported that 30.43% of homicides were due to breakdown of relationship. Aich et al.9 in his study indicated political conflict (22.38%) and land dispute (25.37%) as the major motivating factors. These variations are possible due to the regional and cultural differences existing at each place of study which has a direct influence on the infliction of cut throat injury. In the present study all the cases studied were those brought directly to the morgue without medical intervention i.e. all were brought dead hence it was not possible to study the sequence of events that followed the infliction of cut throat injury. Besides this, the information about the time of injury was retrieved from the police inquest report. The autopsy revealed the major cause of death as due to exsanguinations due to damage to carotid and jugular vessels in 49.95% (n = 34) of cases, followed by asphyxia due to inhalation of blood, in 36.49% (n = 27) of cases. Though carotid, jugular, larynx and trachea were the underlying structures, all were not equally affected due to the varied nature, pattern and depth of the wound. Hence, in few cases aspiration of blood from the severed blood vessels carotid contributed to asphyxia and subsequent death. Similar were the observaions by Buchade et al.7 wherein, they opined that only 65.62% of cases showed carotid artery involvement. The present study also analysed the place of occurrence of the crime. The majority of the incidents of cut throat injuries were reported from a field or farm contributing to 35.14%, followed closely by cases reported from the place of residence, 24.32%. This information was made available from the police reports as the author had visited only few crime scenes. None of the studies available had highlighted the importance of the place of occurrence of the incident. One of the most important observations made in this study was in relation to the weapons. Machete was the commonest weapon of choice, the possibility of easy accessibility of machete with the individuals working in a field or farm was considered to be one of the major factors influencing its usage in the crime. The present autopsy study also highlighted the importance of cut throat injury and fatality which was different from the similar studies elsewhere. In 62.16% of cases the cut throat injury was associated with multiple chop wounds over other parts of the body, in 18 cases stab wounds were present on other parts of the body. Lacerations and gunshot wounds were present in 12 and 7 cases respectively. This was suggestive of repeated unsuccessful attempts ending up with fatal cut throat injury. In 13.51% of cases the cut throat injury was secondary to the fatal wounds inflicted on other parts of the body, hence the infliction of cut throat injury in those cases is possibly due to a failed attempt to decapitate and conceal the identity. The majority of individuals affected in the present study were those belonging to the low socioeconomic class, contributing to 91.89% of cases and the high economic class involved 5.41% of cases. These observations were in sharp contrast to those made by Bhattacharjee et al.13 where, only 69.23% of cases belonged to the low socioeconomic group. In the present study, the middle income group was left untouched; further study is required for the indepth analysis of these groups. The study of direction of the cut throat wound revealed that the majority of the wounds were directed from left to right in 75.68% of cases; similar were the observations made by Buchade et al.7 This is possibly due to the right hand dominance of the majority of the individuals. The commonest weapon of choice was machete reported in 83.78% of cases, followed by meat cleaver, in 10.81% of cases. This preponderance is possibly due to the nature of occupation in the region or type of weapon commonly used. In Jamaica, machete is the commonest weapon used both in farms and at home. Hence, due to easy availability, access and familiarity of the weapon, it has become the choicest weapon of assault. Many of the weapons were retrieved from the scene of crime and others were implied based on the underlying damage to the cervical vertebrae, depth of wound and margins. In the present study it was difficult to estimate the fatal period between the time of infliction and death due to the fact that it was brought directly from the scene of crime, after police got the information about the incident. This study impresses upon the fact that not all cut throat injuries are fatal and they may be only secondary to other fatal injuries on the body like gunshot wound, stab wound and chop wound. In the majority of cases though, major vessels of the neck were involved, the individuals died due to aspiration of blood in the respiratory passage, a condition which could have been avoided by first aid or primary care of the patient. Similarly if immediate medical and surgical measures are adopted many lives can be saved by preventing further haemorrhage related complications. The major preferred sites of the neck were zone II involving 66.21% of cases, followed by zone I contributing to 32.43%. The results were close to the observations made by Aich et al.9 and Gilyoma et al. 12 wherein they concluded, 74.63% and 65.3% of victims were affected at the zone-II level of the neck respectively. The study highlights the correlation of zone levels of the neck, the underlying structures affected and their contribution to fatality, adding further information on the emergency preparedness to cut throat injuries. Hence prevention of loss of blood and emergency blood transfusion can save majority of the lives in cut throat injuries. 5. Conclusions 1. Majority of cut throat injuries are homicidal in nature. 2. Majority of cut throat injuries are associated with gang related violence and relationship crisis. 3. The commonest cause of death apart from exsanguinations was asphyxia, as a result of aspiration of blood in the respiratory passage. 4. In many cases cut throat injury may be only secondary to other fatal injuries like gunshot wounds, stab wounds and chop wounds. 5. Zone II level of the neck is most commonly affected. Funding No external funds were received to conduct the study. Conflict of interest The present study has no financial or personal relationship with any person or organization. Ethical approval Ministry’s Ethics Committee had approved the study although it was a postmortem based study. Acknowledgements Legal Medicine Unit, Ministry of National Security, Kingston Public Hospital, Roberts Funeral Home, Bureau of Special Investigation, Major Investigation Team. References 1 Farlex dictionary, citing: Webster’s Revised Unabridged Dictionary, published 1913 by C. & G. Merriam Co 2 Pranav Prajapati, M.I. Sheikh A study of homicidal deaths by mechanical injuries in Surat, Gujarat J Indian Acad Forensic Med, 32 (2) (2010), pp. 134-138 View Record in Scopus 3 B.C. Okoye, A.J. Oteri Cut throat injuries in Port Harcourt Sahel Med J, 4 (2001), pp. 207-209 View Record in Scopus 4 M. Vassalini, A. Verzeletti, F. De Ferrari Sharp force injury fatalities: a retrospective study (1982–2012) in Brescia (Italy) J Forensic Sci (2014) 5 C. Brunel, C. Fermanian, M. Durigon, G.L. de la Grandmaison Homicidal and suicidal sharp force fatalities: autopsy parameters in relation to the manner of death Forensic Sci Int, 198 (1–3) (2010 May 20), pp. 150-154 ArticleDownload PDFView Record in Scopus 6 D. Demetriades, J.A. Asensio, G. Velmahos, E. Thal Complex problems in penetrating neck trauma Surg Clin North America, 76 (1996), pp. 661-683 ArticleDownload PDFView Record in Scopus 7 Dhiraj Buchade, Hemant Kukde, R. Dere, Rajesh Savardekar, Nilesh Devraj, Amol Maiyyar Autopsy study of cut throat cases brought to Morgue of Sion Hospital, Mumbai – a three year study IJFMT, 6 (2) (July–December 2012) 8 B. Ozdemir, O. Celbis, A. Kaya Cut throat injuries and honor killings: review of 15 cases in eastern Turkey J Forensic Leg Med, 20 (4) (2013 May), pp. 198-203 ArticleDownload PDFView Record in Scopus 9 Manilal Aich, A.B.M. Khorshed Alam, Debesh Chandra Talukder, M.A. Rouf Sarder, Abu Yousuf Fakir, Monir Hossain Cut throat injury: review of 67 cases Bangladesh J Otorhinolaryngol, 17 (1) (2011) 10 K.R. Iseh, A. Obembe Anterior neck injuries presenting as cut throat emergencies in a tertiary health institution in north western Nigeria Niger J Med, 20 (4) (2011 Oct–Dec), pp. 475-478 View Record in Scopus 11 L.O. Onotai, U. Ibekwe The pattern of cut throat injuries in the University of Port-Harcout Teaching Hospital Portharcourt, 19 (3) (2011) 12 J.M. Gilyoma, K.A. Hauli, P.L. Chalya Cut throat injuries at a university teaching hospital in northwestern Tanzania: a review of 98 cases BMC Emerg Med, 14 (14) (2014 Jan), p. 1 13 N. Bhattacharjee, S.M. Arefin, S.M. Mazumder, M.K. Khan Cut throat injury: a retrospective study of 26 cases Bangladesh Med Res Counc Bull, 23 (3) (1997 Dec), pp. 87-90 View Record in Scopus Peer review under responsibility of The International Association of Law and Forensic Sciences (IALFS). Copyright © 2014 Production and hosting by Elsevier B.V. Recommended articles Cut throat injuries and honor killings: Review of 15 cases in eastern Turkey Journal of Forensic and Legal Medicine, Volume 20, Issue 4, 2013, pp. 198-203 Purchase PDFView details Study of gunshot residues from Sintox® ammunition containing marking substances Egyptian Journal of Forensic Sciences, Volume 5, Issue 4, 2015, pp. 174-179 Download PDFView details Canine index – A tool for sex determination Egyptian Journal of Forensic Sciences, Volume 5, Issue 4, 2015, pp. 157-161 Download PDFView details 12Next Category:GC Writers Resources